When Payers Know the Price of Everything

Complexity in the US healthcare system isn’t new, and neither is the debate over drug costs. What’s changed is the tone. In dozens of conversations we’ve had this year with pharmacy directors at large national and regional health plans, pharmacy benefit managers (PBMs), and integrated delivery networks, we’ve noticed something new: Payers are talking about the growing number of publicly visible drug prices not as background noise, but as leverage.

Call it Oscar Wilde’s cynic, updated for 2026: Now that payers can essentially “know the price of everything,” are they focused solely on the lowest number, losing sight of value altogether?

The Medicare Maximum Fair Price (MFP) is the most obvious new benchmark, but it’s far from the only one. Direct-to-patient (DTP) cash offers on brand websites, novel programs like Eli Lilly’s Employer Direct, and the swirl of speculation around the Most-Favored-Nation (MFN) executive order are all adding new, visible price points into a market that used to keep most of its numbers behind closed doors.

For manufacturers, the risk isn’t that any single price point forces a renegotiation. It’s that enough of these benchmarks start becoming commercially actionable at once, especially in crowded therapeutic categories where payers already have leverage to work with.

Three things stood out across our conversations: MFP spillover is real but selective; DTP pricing has become a payer-facing decision in its own right; and payer economics are diverging enough that no single benchmark will land the same way twice.

MFP: Leverage, Not Mandate

The MFP is a Medicare price. It carries no statutory weight in commercial contracting. But several pharmacy directors told us plainly that they’re using it anyway. One integrated purchaser described extending a major new discount on an oncology asset directly into commercial negotiations. Another payer, in a category where deep discounts already existed, said the MFP barely moved the needle.

The pattern: MFP spillover shows up when the public price sits meaningfully below current net cost and the payer has a real way to act on it, whether that’s shifting volume, adjusting formulary tier, or steering through a preferred pathway. Without that ability to act, the number is just a number.

How DTP Pricing Changes the Conversation

If there’s one category proving this point in real time, it’s GLP-1s. High demand, spotty coverage, and visible cash prices have collided to put DTP pricing squarely on the payer’s desk. As one plan executive told us, “DTP access can be attractive, but it de-aggregates the whole system,” a comment which reflects a real concern about fragmented medication records and safety data, not just a talking point.

Still, the comparison payers are drawing between cash price and rebate is more visible than it is automatically valid. Dose, form, duration, eligibility, and government-pricing exposure all affect whether that comparison actually holds up. That’s exactly why manufacturers need an answer ready before the question gets asked, not after.

MFN: Political Theater, Real Reference Points

Ask a payer about MFN and you’ll likely hear some reference to “political theater.” One pharmacy director called it “a big black hole” that plans can’t yet operationalize. But theater still gets watched, and every voluntary MFN agreement and Centers for Medicare & Medicaid Services (CMS) proposal for international-price-linked Medicaid models adds another visible reference point to the pile, even without a consistent mechanism behind it.

PBM reform is following a similar script. One payer told us to expect rebates to “reappear under a different label.” Another put it more bluntly: “It’s just about the net. I don’t care how I get there.” The market isn’t converging on one model. A rebate-dependent plan, a true-net-cost plan, and an integrated purchaser will each respond to the same benchmark differently, which is exactly why a national playbook won’t hold up account by account.

What Does This Mean for Manufacturers?

The real question isn’t whether these benchmarks exist. They clearly do, and more are coming. It’s which accounts can actually convert a visible price into a negotiation tool, and whether the manufacturer is ready before that demand is made.

That starts with mapping exposure at the asset, category, and account level. It means pre-building the comparability argument: the specific evidence and objection handlers for channel, dose, service, and eligibility differences that support the value story.

It means matching contract strategy to each account’s economics rather than a one-size-fits-all response. And it means putting real governance around every public price move, so a DTP launch, a low wholesale acquisition cost decision, or an employer-specific deal doesn’t create a benchmark nobody planned for.

Price transparency isn’t going away, and neither is the pressure it creates. But a defensible evidence package for value, paired with account-specific strategy, is still the best answer to a payer holding a price list and asking, “Why not us, too?”

Robert Rouse is a partner at Beghou and head of its value & access practice.